Summary of Benefits 2019 Summary of... · 2019. 2. 12. · 2019 PUB Name: GSB014...
Transcript of Summary of Benefits 2019 Summary of... · 2019. 2. 12. · 2019 PUB Name: GSB014...
2019
PUB Name: GSB014
Y0040_GHHKCFJEN19_M (Pending CMS Approval) PPO 079/429
Summary of Benefits Humana Medicare Employer TM PPO Plan
PPO 079/429 Maine-Endwell Central School District
Our service area includes the following: Alabama : Autauga, Baldwin, Barbour, Bibb, Blount, Bullock, Butler, Chambers, Cherokee, Chilton, Choctaw, Clarke, Clay, Cleburne, Coffee, Colbert, Conecuh, Coosa, Covington, Crenshaw, Cullman, Dale, Dallas, Elmore, Escambia, Etowah, Fayette, Franklin, Geneva, Greene, Hale, Henry, Houston, Jackson, Jefferson, Lamar, Lauderdale, Lee, Limestone, Lowndes, Macon, Madison, Marengo, Marion, Marshall, Mobile, Monroe, Montgomery, Morgan, Perry, Pickens, Pike, Randolph, Russell, Shelby, St. Clair, Sumter, Talladega, Tallapoosa, Tuscaloosa, Walker, Washington, Wilcox, Winston; Arizona : Coconino, La Paz, Maricopa, Mohave, Pima, Pinal, Santa Cruz, Yavapai, Yuma; Arkansas : Baxter, Benton, Boone, Carroll, Clark, Cleburne, Conway, Craighead, Crawford, Crittenden, Dallas, Faulkner, Franklin, Fulton, Garland, Grant, Greene, Hot Spring, Izard, Jefferson, Johnson, Lee, Logan, Lonoke, Madison, Marion, Montgomery, Nevada, Newton, Perry, Phillips, Pike, Poinsett, Polk, Pope, Prairie, Pulaski, Randolph, Saline, Scott, Searcy, Sebastian, Sharp, St. Francis, Union, Van Buren, Washington, Yell; Colorado : Adams, Alamosa, Arapahoe, Archuleta, Boulder, Broomfield, Chaffee, Clear Creek, Conejos, Costilla, Crowley, Custer, Delta, Denver, Douglas, El Paso, Elbert, Fremont, Gilpin, Grand, Huerfano, Jefferson, La Plata, Larimer, Las Animas, Logan, Mesa, Montezuma, Montrose, Morgan, Otero, Park, Pueblo, Teller, Weld; Delaware : Kent, New Castle, Sussex; Florida : Alachua, Baker, Bay, Bradford, Brevard, Broward, Calhoun, Charlotte, Citrus, Clay, Collier, Columbia, DeSoto, Dixie, Duval, Escambia, Flagler, Gadsden, Gilchrist, Glades, Gulf, Hamilton, Hardee, Hendry, Hernando, Highlands, Hillsborough, Holmes, Indian River, Jefferson, Lafayette, Lake, Lee, Levy, Liberty, Madison, Manatee, Marion, Martin, Miami-Dade, Nassau, Okaloosa, Okeechobee, Orange, Osceola, Palm Beach, Pasco, Pinellas, Polk, Putnam, Santa Rosa, Sarasota, Seminole, St. Johns, St. Lucie, Sumter, Suwannee, Union, Volusia, Wakulla, Walton, Washington; Georgia : Appling, Atkinson, Bacon, Baker, Baldwin, Banks, Barrow, Bartow, Berrien, Bibb, Bleckley, Brantley, Bryan, Bulloch, Burke, Butts, Camden, Carroll, Catoosa, Charlton, Chatham, Chattahoochee, Chattooga, Cherokee, Clarke, Clayton, Clinch, Cobb, Coffee, Columbia, Coweta, Crawford, Dade, Dawson, DeKalb, Dodge, Dooly, Dougherty, Douglas, Effingham, Elbert, Evans, Fannin, Fayette, Floyd, Forsyth, Franklin, Fulton, Gilmer, Glascock, Glynn, Gordon, Greene, Gwinnett, Habersham, Hall, Hancock, Haralson, Harris, Hart, Heard, Henry, Houston, Irwin, Jackson, Jasper, Jefferson, Jenkins, Johnson, Jones, Lamar, Laurens, Lee, Liberty, Lincoln, Long, Lumpkin, Macon, Madison, Marion, McDuffie, McIntosh, Meriwether, Monroe, Montgomery, Morgan, Murray, Muscogee, Newton, Oconee, Oglethorpe, Paulding, Peach, Pickens, Pierce, Pike, Polk, Putnam, Quitman, Rabun, Randolph, Richmond, Rockdale, Schley, Screven, Spalding, Stephens, Stewart, Sumter, Talbot, Taliaferro, Tattnall, Taylor, Terrell, Towns, Troup, Turner, Twiggs, Union, Upson, Walton, Ware, Warren, Washington, Wayne, Webster, Wheeler, White, Wilkes, Worth; Hawaii : Honolulu, Kauai, Maui; Idaho : Ada, Boise, Bonner, Canyon, Gem, Kootenai, Payette; Illinois : Adams, Boone, Brown, Cass, Christian, Clark, Cook, DeKalb, DuPage, Edgar, Fulton, Hancock, Henderson, Henry, Jasper, Kane, Kankakee, Kendall, Knox, La Salle, Lake, Lee, Livingston, Madison, Marshall, McDonough, McHenry, McLean, Menard, Mercer, Monroe, Morgan, Moultrie, Ogle, Peoria, Pike, Putnam, Richland, Rock Island, Sangamon, Schuyler, Scott, St. Clair, Stark, Stephenson, Tazewell, Vermilion, Warren, Will, Winnebago, Woodford; Indiana : Adams, Allen, Bartholomew, Benton, Blackford, Boone, Brown, Carroll, Cass, Clark, Clay, Clinton, Daviess, De Kalb, Dearborn, Decatur, Delaware, Dubois, Elkhart, Fayette, Floyd, Fountain, Franklin, Fulton, Gibson, Grant, Greene, Hamilton, Hancock, Harrison, Hendricks, Henry, Howard, Huntington, Jackson, Jasper, Jay, Jefferson, Jennings, Johnson, Knox, Kosciusko, La Porte, Lagrange, Lake, Lawrence, Madison, Marion, Marshall, Martin, Miami, Monroe, Montgomery, Morgan, Newton, Noble, Ohio, Orange, Owen, Parke, Perry, Pike, Porter, Posey, Pulaski, Putnam, Randolph, Ripley, Rush, Scott, Shelby, Spencer, St. Joseph, Starke, Steuben, Sullivan, Switzerland, Tippecanoe, Tipton, Union, Vanderburgh, Vermillion, Vigo, Wabash, Warren, Warrick, Washington, Wayne, Wells, White, Whitley; Iowa : Adair, Allamakee, Audubon, Benton, Black Hawk, Boone, Buchanan, Buena
Vista, Butler, Calhoun, Carroll, Cass, Cedar, Cerro Gordo, Cherokee, Clayton, Clinton, Crawford, Dallas, Davis, Decatur, Delaware, Dickinson, Emmet, Floyd, Franklin, Fremont, Grundy, Hamilton, Hancock, Hardin, Harrison, Henry, Humboldt, Ida, Iowa, Jackson, Jasper, Jefferson, Johnson, Jones, Keokuk, Kossuth, Lee, Linn, Lucas, Lyon, Madison, Mahaska, Marion, Marshall, Mills, Monona, Monroe, Muscatine, O'Brien, Osceola, Page, Palo Alto, Plymouth, Pocahontas, Polk, Pottawattamie, Poweshiek, Ringgold, Sac, Scott, Sioux, Story, Tama, Union, Van Buren, Wapello, Warren, Washington, Wayne, Webster, Winnebago, Winneshiek, Woodbury, Worth, Wright; Kansas : Atchison, Bourbon, Butler, Cherokee, Cowley, Crawford, Dickinson, Douglas, Franklin, Harvey, Jefferson, Johnson, Labette, Leavenworth, Linn, McPherson, Miami, Ottawa, Pottawatomie, Reno, Sedgwick, Shawnee, Sumner, Wyandotte; Kentucky : Adair, Allen, Anderson, Ballard, Barren, Bath, Bell, Boone, Bourbon, Boyd, Boyle, Bracken, Breathitt, Breckinridge, Bullitt, Butler, Caldwell, Calloway, Campbell, Carlisle, Carroll, Carter, Casey, Clark, Clay, Clinton, Crittenden, Cumberland, Daviess, Edmonson, Elliott, Estill, Fayette, Fleming, Floyd, Franklin, Fulton, Gallatin, Garrard, Grant, Graves, Grayson, Green, Greenup, Hancock, Hardin, Harlan, Harrison, Hart, Henderson, Henry, Hickman, Hopkins, Jackson, Jefferson, Jessamine, Johnson, Kenton, Knott, Knox, Larue, Laurel, Lawrence, Lee, Leslie, Letcher, Lewis, Lincoln, Livingston, Logan, Lyon, Madison, Magoffin, Marion, Marshall, Martin, Mason, McCracken, McCreary, McLean, Meade, Menifee, Mercer, Metcalfe, Monroe, Montgomery, Morgan, Muhlenberg, Nelson, Nicholas, Ohio, Oldham, Owen, Owsley, Pendleton, Perry, Pike, Powell, Pulaski, Robertson, Rockcastle, Rowan, Russell, Scott, Shelby, Simpson, Spencer, Taylor, Todd, Trigg, Trimble, Union, Warren, Washington, Wayne, Webster, Whitley, Wolfe, Woodford; Louisiana : Allen, Avoyelles, Beauregard, Bienville, Calcasieu, Caldwell, Cameron, Claiborne, De Soto, Evangeline, Jefferson Davis, Lafayette, LaSalle, Morehouse, Natchitoches, Ouachita, Red River, Sabine, St. Bernard, St. Landry, St. Martin, St. Mary, Vernon, Washington, Winn; Maine : Androscoggin, Cumberland, Kennebec, Knox, Lincoln, Oxford, Penobscot, Piscataquis, Sagadahoc, Somerset, Waldo, York; Maryland : Allegany, Anne Arundel, Carroll, Frederick, Garrett, Washington; Michigan : Alcona, Alger, Allegan, Alpena, Antrim, Arenac, Baraga, Barry, Bay, Benzie, Berrien, Branch, Calhoun, Cass, Charlevoix, Cheboygan, Chippewa, Clare, Clinton, Crawford, Delta, Dickinson, Eaton, Emmet, Genesee, Gladwin, Gogebic, Grand Traverse, Gratiot, Hillsdale, Houghton, Huron, Ingham, Ionia, Iosco, Iron, Isabella, Jackson, Kalamazoo, Kalkaska, Kent, Keweenaw, Lake, Lapeer, Leelanau, Lenawee, Livingston, Luce, Mackinac, Macomb, Manistee, Marquette, Mason, Mecosta, Menominee, Midland, Missaukee, Monroe, Montcalm, Montmorency, Muskegon, Newaygo, Oakland, Oceana, Ogemaw, Ontonagon, Osceola, Oscoda, Otsego, Ottawa, Presque Isle, Roscommon, Saginaw, Sanilac, Schoolcraft, Shiawassee, St. Clair, St. Joseph, Tuscola, Van Buren, Washtenaw, Wayne, Wexford; Minnesota : Aitkin, Anoka, Becker, Beltrami, Benton, Big Stone, Blue Earth, Brown, Carlton, Carver, Cass, Chippewa, Chisago, Clay, Clearwater, Cottonwood, Crow Wing, Dakota, Dodge, Douglas, Faribault, Fillmore, Freeborn, Goodhue, Grant, Hennepin, Houston, Hubbard, Isanti, Itasca, Jackson, Kanabec, Kandiyohi, Kittson, Lac qui Parle, Lake, Lake of the Woods, Le Sueur, Lincoln, Lyon, Mahnomen, Marshall, Martin, McLeod, Meeker, Mille Lacs, Morrison, Mower, Murray, Nicollet, Nobles, Norman, Olmsted, Otter Tail, Pennington, Pine, Pipestone, Polk, Pope, Ramsey, Red Lake, Redwood, Renville, Rice, Rock, Roseau, Scott, Sherburne, Sibley, St. Louis, Stearns, Steele, Swift, Todd, Wabasha, Wadena, Waseca, Washington, Watonwan, Wilkin, Winona, Wright; Mississippi : Amite, Attala, Benton, Bolivar, Calhoun, Carroll, Chickasaw, Choctaw, Claiborne, Clarke, Clay, Coahoma, Copiah, DeSoto, George, Greene, Hancock, Harrison, Hinds, Holmes, Humphreys, Issaquena, Jackson, Jasper, Jefferson Davis, Kemper, Lauderdale, Lawrence, Leake, Leflore, Lowndes, Madison, Marshall, Monroe, Montgomery, Neshoba, Newton, Noxubee, Oktibbeha, Panola, Pearl River, Quitman, Rankin, Scott, Sharkey, Simpson, Smith, Stone, Tallahatchie, Tate, Tishomingo, Tunica, Walthall, Washington, Wayne, Webster, Wilkinson, Winston, Yalobusha, Yazoo; Missouri : Adair, Audrain, Barry, Bates, Benton,
Bollinger, Boone, Caldwell, Callaway, Camden, Carroll, Carter, Cass, Cedar, Christian, Clay, Cole, Cooper, Crawford, Dade, Dallas, Daviess, DeKalb, Douglas, Franklin, Gentry, Greene, Grundy, Harrison, Henry, Hickory, Howard, Howell, Jackson, Jasper, Jefferson, Johnson, Laclede, Lafayette, Lawrence, Lincoln, Livingston, Macon, McDonald, Miller, Mississippi, Moniteau, Monroe, Montgomery, Morgan, Newton, Oregon, Osage, Ozark, Pemiscot, Pettis, Phelps, Platte, Polk, Pulaski, Ray, Reynolds, Saline, Schuyler, Scotland, Scott, Shelby, St. Charles, St. Clair, St. Francois, St. Louis, St. Louis City, Ste. Genevieve, Stoddard, Stone, Sullivan, Taney, Texas, Vernon, Warren, Washington, Wayne, Webster, Wright; Montana : Beaverhead, Broadwater, Carbon, Cascade, Chouteau, Deer Lodge, Fergus, Flathead, Granite, Jefferson, Judith Basin, Lake, Lewis and Clark, Liberty, Lincoln, Madison, Meagher, Mineral, Missoula, Pondera, Powell, Ravalli, Sanders, Silver Bow, Stillwater, Teton, Yellowstone; Nebraska : Banner, Burt, Butler, Cass, Cheyenne, Colfax, Cuming, Dodge, Douglas, Kimball, Lancaster, Otoe, Sarpy, Saunders, Seward, Washington; Nevada : Clark, Washoe; New Hampshire : Belknap, Carroll, Hillsborough, Merrimack, Rockingham, Strafford; New Jersey : Bergen, Burlington, Camden, Gloucester, Hudson, Morris; New Mexico : Bernalillo, Catron, Chaves, Cibola, Colfax, Curry, Dona Ana, Grant, Guadalupe, Lincoln, Los Alamos, Luna, McKinley, Otero, Rio Arriba, San Juan, San Miguel, Sandoval, Santa Fe, Sierra, Socorro, Taos, Torrance, Valencia; New York : Albany, Allegany, Bronx, Broome, Cattaraugus, Cayuga, Chautauqua, Chemung, Chenango, Columbia, Cortland, Delaware, Greene, Hamilton, Herkimer, Jefferson, Kings, Lewis, Madison, Montgomery, Nassau, New York, Oneida, Onondaga, Oswego, Queens, Rensselaer, Richmond, Rockland, Saratoga, Schenectady, Schuyler, Seneca, Steuben, Tioga, Warren, Washington, Yates; North Carolina : Alamance, Alexander, Alleghany, Anson, Ashe, Avery, Bertie, Bladen, Brunswick, Buncombe, Burke, Cabarrus, Caldwell, Camden, Caswell, Catawba, Chatham, Cherokee, Chowan, Clay, Cleveland, Columbus, Cumberland, Currituck, Davidson, Davie, Duplin, Durham, Forsyth, Franklin, Gaston, Gates, Graham, Granville, Greene, Guilford, Halifax, Harnett, Haywood, Henderson, Hertford, Hyde, Iredell, Jackson, Johnston, Jones, Lee, Lenoir, Lincoln, Macon, Madison, McDowell, Mecklenburg, Mitchell, Montgomery, Moore, New Hanover, Northampton, Orange, Pasquotank, Pender, Perquimans, Person, Polk, Randolph, Richmond, Rockingham, Rowan, Rutherford, Sampson, Scotland, Stanly, Stokes, Surry, Swain, Transylvania, Tyrrell, Union, Vance, Wake, Warren, Washington, Watauga, Wilkes, Wilson, Yadkin, Yancey; North Dakota : Barnes, Burleigh, Cass, Grand Forks, Kidder, Morton, Richland, Stutsman, Traill; Ohio : Adams, Allen, Ashland, Ashtabula, Athens, Auglaize, Belmont, Brown, Butler, Carroll, Champaign, Clark, Clermont, Clinton, Columbiana, Coshocton, Crawford, Cuyahoga, Darke, Defiance, Delaware, Erie, Fairfield, Fayette, Franklin, Fulton, Gallia, Geauga, Greene, Guernsey, Hamilton, Hancock, Hardin, Harrison, Henry, Highland, Hocking, Holmes, Huron, Jackson, Jefferson, Knox, Lake, Lawrence, Licking, Logan, Lorain, Lucas, Madison, Mahoning, Marion, Medina, Meigs, Mercer, Miami, Monroe, Montgomery, Morgan, Morrow, Muskingum, Noble, Ottawa, Paulding, Perry, Pickaway, Pike, Portage, Preble, Putnam, Richland, Ross, Sandusky, Scioto, Seneca, Shelby, Stark, Summit, Trumbull, Tuscarawas, Union, Van Wert, Vinton, Warren, Washington, Wayne, Williams, Wood, Wyandot; Oklahoma : Adair, Canadian, Cherokee, Cleveland, Comanche, Craig, Creek, Custer, Delaware, Dewey, Grady, Haskell, Hughes, Johnston, Kay, Kingfisher, Kiowa, Le Flore, Lincoln, Logan, Mayes, McClain, McIntosh, Muskogee, Noble, Nowata, Oklahoma, Okmulgee, Osage, Ottawa, Pawnee, Payne, Pittsburg, Pottawatomie, Pushmataha, Rogers, Seminole, Sequoyah, Stephens, Tulsa, Wagoner; Oregon : Benton, Clackamas, Columbia, Crook, Deschutes, Hood River, Jefferson, Lincoln, Linn, Malheur, Multnomah, Washington; Pennsylvania : Adams, Allegheny, Beaver, Bedford, Berks, Blair, Bradford, Bucks, Butler, Cambria, Cameron, Carbon, Centre, Chester, Clarion, Clearfield, Clinton, Columbia, Crawford, Cumberland, Dauphin, Delaware, Elk, Erie, Fayette, Forest, Franklin, Fulton, Greene, Huntingdon, Indiana, Juniata, Lackawanna, Lancaster, Lawrence, Lebanon, Lehigh, Luzerne, Lycoming, McKean, Mercer, Mifflin, Monroe, Montgomery, Montour,
Northampton, Northumberland, Perry, Philadelphia, Potter, Schuylkill, Snyder, Somerset, Sullivan, Susquehanna, Tioga, Union, Venango, Warren, Washington, Wayne, Westmoreland, Wyoming, York; Puerto Rico : Island Wide; South Carolina : Abbeville, Aiken, Allendale, Anderson, Bamberg, Barnwell, Beaufort, Berkeley, Calhoun, Charleston, Cherokee, Chester, Colleton, Dorchester, Edgefield, Fairfield, Georgetown, Greenville, Hampton, Horry, Jasper, Kershaw, Lancaster, Laurens, Lee, Lexington, McCormick, Newberry, Oconee, Orangeburg, Pickens, Richland, Saluda, Spartanburg, Union, York; South Dakota : Bon Homme, Brookings, Butte, Clark, Clay, Codington, Custer, Davison, Day, Deuel, Fall River, Grant, Hamlin, Hanson, Hutchinson, Kingsbury, Lake, Lawrence, Lincoln, Marshall, McCook, Meade, Miner, Minnehaha, Moody, Pennington, Roberts, Sanborn, Spink, Turner, Union, Yankton; Tennessee : Anderson, Bedford, Bledsoe, Blount, Bradley, Campbell, Cannon, Cheatham, Claiborne, Cocke, Coffee, Cumberland, Davidson, Decatur, DeKalb, Dickson, Dyer, Fayette, Fentress, Franklin, Giles, Grainger, Grundy, Hamblen, Hamilton, Hardin, Haywood, Henderson, Hickman, Houston, Humphreys, Jackson, Jefferson, Knox, Lauderdale, Lawrence, Lewis, Loudon, Macon, Madison, Marion, Marshall, Maury, Meigs, Monroe, Montgomery, Moore, Morgan, Obion, Overton, Pickett, Polk, Rhea, Roane, Robertson, Rutherford, Scott, Sequatchie, Sevier, Shelby, Smith, Stewart, Sumner, Trousdale, Union, Warren, Wayne, Weakley, White, Williamson; Texas : Anderson, Aransas, Armstrong, Atascosa, Austin, Bandera, Bastrop, Bee, Bell, Bexar, Bosque, Brazoria, Brazos, Brooks, Burleson, Burnet, Caldwell, Calhoun, Callahan, Cameron, Camp, Carson, Chambers, Cherokee, Coleman, Collin, Colorado, Comal, Comanche, Cooke, Coryell, Dallas, Dawson, Deaf Smith, Delta, Denton, Dimmit, Eastland, Ector, Edwards, El Paso, Ellis, Erath, Falls, Fannin, Fayette, Fort Bend, Franklin, Frio, Galveston, Gray, Grayson, Gregg, Grimes, Guadalupe, Hamilton, Hardin, Harris, Harrison, Hays, Henderson, Hidalgo, Hill, Hood, Howard, Hudspeth, Hunt, Jefferson, Jim Wells, Johnson, Jones, Karnes, Kaufman, Kendall, Kenedy, Kerr, Kinney, Kleberg, Lampasas, Lee, Leon, Liberty, Live Oak, Llano, Lubbock, Marion, Martin, Matagorda, Maverick, McLennan, Medina, Midland, Milam, Montgomery, Morris, Navarro, Nueces, Orange, Palo Pinto, Panola, Parker, Polk, Potter, Randall, Real, Refugio, Robertson, Rockwall, Rusk, San Jacinto, San Patricio, Shackelford, Shelby, Smith, Tarrant, Taylor, Tom Green, Travis, Trinity, Tyler, Upshur, Uvalde, Van Zandt, Victoria, Walker, Waller, Washington, Webb, Wharton, Williamson, Wilson, Wise, Wood, Zavala; Utah : Davis, Salt Lake, Utah, Washington, Weber; Virginia : Accomack, Albemarle, Alexandria City, Alleghany, Amelia, Amherst, Appomattox, Arlington, Bedford, Bland, Botetourt, Bristol City, Buchanan, Buckingham, Buena Vista City, Campbell, Caroline, Charlotte, Charlottesville City, Chesapeake City, Chesterfield, Clarke, Colonial Heights City, Covington City, Craig, Cumberland, Danville City, Dickenson, Dinwiddie, Essex, Falls Church City, Fauquier, Floyd, Fluvanna, Franklin, Franklin City, Frederick, Fredericksburg City, Giles, Gloucester, Goochland, Grayson, Greene, Halifax, Hampton City, Hanover, Henrico, Henry, Hopewell City, Isle of Wight, James City, King and Queen, King George, Lancaster, Lee, Loudoun, Louisa, Lunenburg, Lynchburg City, Madison, Manassas City, Manassas Park City, Martinsville City, Mecklenburg, Middlesex, Montgomery, Nelson, New Kent, Newport News City, Norfolk City, Northampton, Northumberland, Norton City, Nottoway, Orange, Page, Petersburg City, Pittsylvania, Poquoson City, Portsmouth City, Powhatan, Prince George, Prince William, Pulaski, Radford City, Rappahannock, Richmond, Richmond City, Roanoke, Roanoke City, Russell, Salem City, Scott, Shenandoah, Smyth, Southampton, Spotsylvania, Stafford, Suffolk City, Surry, Sussex, Tazewell, Virginia Beach City, Warren, Washington, Westmoreland, Williamsburg City, Winchester City, Wise, Wythe, York; Washington : Clark, Cowlitz, Island, King, Kitsap, Kittitas, Pierce, Skagit, Snohomish, Spokane, Thurston, Walla Walla, Whatcom; West Virginia : Barbour, Berkeley, Boone, Braxton, Brooke, Cabell, Calhoun, Clay, Doddridge, Fayette, Gilmer, Grant, Greenbrier, Hampshire, Hancock, Hardy, Harrison, Jackson, Jefferson, Kanawha, Lewis, Lincoln, Logan, Marion, Marshall, Mason, McDowell, Mercer, Mineral, Mingo, Monongalia, Monroe, Morgan, Nicholas, Ohio, Pendleton,
Pleasants, Pocahontas, Preston, Putnam, Raleigh, Randolph, Ritchie, Roane, Summers, Taylor, Tucker, Tyler, Upshur, Wayne, Webster, Wetzel, Wirt, Wood, Wyoming; Wisconsin : Brown, Calumet, Columbia, Crawford, Dane, Dodge, Door, Douglas, Fond du Lac, Forest, Green, Green Lake, Iowa, Jefferson, Kenosha, Kewaunee, Lafayette, Manitowoc, Marathon, Marinette, Marquette, Menominee, Milwaukee, Oconto, Outagamie, Ozaukee, Portage, Racine, Richland, Rock, Sauk, Sheboygan, Washington, Waukesha, Waupaca, Waushara, Winnebago
The employer, union or trust determines where they are going to offer the plan.
2019 -7- Summary of Benefits
ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Para obtener información adicional, llame a Servicio al cliente al número de teléfono que aparece anteriormente.
Let's talk about Humana Medicare Employer PPO, Find out more about the Humana Medicare Employer PPO plan – including the services it covers – in this easy-to-use guide.
The benefit information provided is a summary of what we cover and what you pay. It doesn't list every service that we cover or list every limitation or exclusion. For a complete list of services we cover, ask us for the "Evidence of Coverage" or you will receive one after you enroll.
To be eligible To join Humana Medicare Employer PPO, you must be entitled to Medicare Part A, be enrolled in Medicare Part B, and live in our service area. The counties listed earlier in this booklet are covered in the Humana network. However, if your county is not listed, you may still have coverage with this plan. If you don't live in one of these areas, please contact the plan to see if you are eligible.
Plan name: Humana Medicare Employer PPO
How to reach us: Non-Union members should call toll-free 1-866-396-8810 for questions (TTY/TDD 711) .
Call Monday – Friday, 8 a.m. - 9 p.m. Eastern time.
Or visit our website: Humana.com A healthy partnership Get more from your plan — with extra services and resources provided by Humana!
Humana Medicare Employer PPO has a network of doctors, hospitals, and other providers. If you use the providers in our network, you may pay less for your covered services. But if you want to, you can also use providers that are not in our network. You may have to pay more for the services you receive outside the network, and you may have to follow special rules prior to getting services in and/or out of network. For more information, please call Group Medicare Customer Care.
Note: some services require prior authorization and referrals from providers. 2019 -8- Summary of Benefits Note: some services require prior authorization and referrals from providers.
Monthly Premium, Deductible and Limits - IN-NETWORK OUT-OF-NETWORK PLAN COSTS Monthly premium You must keep paying your Medicare Part B premium.
For information concerning the actual premiums you will pay, please contact your employer/union group.
Medical deductible This plan does not have a deductible.
Maximum out-of-pocket responsibility The most you pay for copays, coinsurance and other costs for medical services for the year.
In-Network Maximum Out-of-Pocket $1,000 out-of-pocket limit for Medicare-covered services. The following services do not apply to the maximum out-of-pocket: Part D Pharmacy, Fitness Program ; Health Education Services ; Meal Benefit ; Nursing Hotline ; Smoking Cessation (Additional) ; Web/Phone Based Technologies and the Plan Premium.
If you reach the limit on out-of-pocket costs, you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year.
Combined In and Out-of-Network Maximum Out-of-Pocket $1,000 out-of-pocket limit for Medicare-covered services. In-Network Exclusions: Part D Pharmacy, Fitness Program ; Health Education Services ; Meal Benefit ; Nursing Hotline ; Smoking Cessation (Additional) ; Web/Phone Based Technologies and the Plan Premium do not apply to the combined maximum out-of-pocket.
Out-of-Network Exclusions: Part D Pharmacy, Worldwide Coverage and the Plan Premium do not apply to the combined maximum out-of-pocket.
Your limit for services received from in-network providers will count toward this limit.
If you reach the limit on out-of-pocket costs, you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year.
Note: some services require prior authorization and referrals from providers. 2019 -9- Summary of Benefits
Covered Medical and Hospital Benefits - IN-NETWORK OUT-OF-NETWORK ACUTE INPATIENT HOSPITAL CARE Our plan covers an unlimited number of days for an inpatient hospital stay. Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital.
$0 per admit $0 per admit
OUTPATIENT HOSPITAL COVERAGE Outpatient hospital visits $0 copay $0 copay
Ambulatory surgical center $0 copay $0 copay
DOCTOR OFFICE VISITS Primary care provider (PCP) $0 copay $0 copay
Specialists $0 copay $0 copay
PREVENTIVE CARE Including: Annual Wellness Visit, flu vaccine, colorectal cancer and breast cancer screenings. Covered at no cost when you see an in-network provider. Any additional preventive services approved by Medicare during the contract year will be covered.
Covered at no cost when you see an in-network provider.
$0 copay for Medicare-covered preventive services $0 copay for a supplemental annual physical exam
EMERGENCY CARE Emergency room $0 copay for Medicare-covered
emergency room visit(s) $0 copay for Medicare-covered emergency room visit(s)
Urgently needed services Urgently needed services are care provided to treat a non-emergency, unforeseen medical illness, injury or condition that requires immediate medical attention.
$0 copay $0 copay
DIAGNOSTIC SERVICES, LABS AND IMAGING Diagnostic radiology $0 copay $0 copay
Lab services $0 copay $0 copay
Diagnostic tests and procedures $0 copay $0 copay
Note: some services require prior authorization and referrals from providers. 2019 -10- Summary of Benefits
Covered Medical and Hospital Benefits - IN-NETWORK OUT-OF-NETWORK Outpatient X-rays $0 copay $0 copay
Radiation Therapy $0 copay $0 copay
HEARING SERVICES Medicare covered hearing $0 copay $0 copay
Routine hearing
DENTAL SERVICES Medicare covered dental VISION SERVICES Medicare covered vision services
$0 copayment for fitting/evaluation up to 1 every 2 years. $0 copayment for routine hearing test up to 1 every 3 years. $400 maximum benefit coverage amount every 3 years for hearing aids (all types).
$0 copayment for fitting/evaluation up to 1 every 2 years. $0 copayment for routine hearing test up to 1 every 3 years. $400 maximum benefit coverage amount every 3 years for hearing aids (all types). Benefits received out-of-network are subject to any in-network benefit maximums, limitations, and/or exclusions.
$0 copay
$0 copay
Diabetic eye exam $0 copay $0 copay
Eyewear (post-cataract) $0 copay $0 copay
Routine vision $0 copayment for routine exam, refraction up to 1 per year. $100 maximum benefit coverage amount per year for contact lenses or eyeglasses - lenses and frames (includes fitting). Eyeglasses will include ultraviolet protection and scratch resistant coating.
$0 copayment for routine exam, refraction up to 1 per year. $100 maximum benefit coverage amount per year for contact lenses or eyeglasses - lenses and frames (includes fitting). Eyeglasses will include ultraviolet protection and scratch resistant coating. Benefits received out-of-network are subject to any in-network benefit maximums, limitations, and/or exclusions.
$0 copay
$0 copay
Note: some services require prior authorization and referrals from providers. 2019 -11- Summary of Benefits
Covered Medical and Hospital Benefits - IN-NETWORK OUT-OF-NETWORK MENTAL HEALTH SERVICES Inpatient The inpatient hospital care limit applies to inpatient mental services provided in a general hospital. Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital. 190 day lifetime limit in a psychiatric facility
$0 per admit $0 per admit
Outpatient group and individual therapy visits
Outpatient therapy visit: $0 copay $0 copay
SKILLED NURSING FACILITY Our plan covers up to 100 days in a SNF.
No 3-day hospital stay is required. Plan pays $0 after 100 days
$0 copay per day for days 1-100 $0 copay per day for days 1-100
PHYSICAL THERAPY $0 copay $0 copay
AMBULANCE - $0 copay $0 copay
TRANSPORTATION Not covered Not covered
PART B PRESCRIPTION DRUGS - $0 copay or 0% of the cost $0 copay or 0% of the cost
ACUPUNCTURE - $10 copay $10 copay
ALLERGY Allergy Shots & Serum $0 copay $0 copay
CHIROPRACTIC SERVICES Medicare covered chiropractic visit(s)
$0 copay $0 copay
Routine chiropractic visit(s) $10 copay $10 copay
Note: some services require prior authorization and referrals from providers. 2019 -12- Summary of Benefits
Covered Medical and Hospital Benefits - IN-NETWORK OUT-OF-NETWORK DIABETES MANAGEMENT TRAINING - $0 copay $0 copay
FOOT CARE (PODIATRY) Medicare covered foot care $0 copay $0 copay
HOME HEALTH CARE - $0 copay $0 copay
MEDICAL EQUIPMENT/SUPPLIES Durable medical equipment (like wheelchairs or oxygen)
0% of the cost 0% of the cost
Medical Supplies 0% of the cost 0% of the cost
Prosthetics (artificial limbs or braces)
0% of the cost 0% of the cost
Diabetes monitoring supplies $0 copay $0 copay
OUTPATIENT SUBSTANCE ABUSE Outpatient group and individual substance abuse treatment visits
Outpatient substance abuse treatment visit: $0 copay $0 copay
REHABILITATION SERVICES Occupational and speech therapy
$0 copay $0 copay
Cardiac rehabilitation $0 copay $0 copay
Pulmonary rehabilitation $0 copay $0 copay
RENAL DIALYSIS Renal dialysis $0 copay $0 copay
Kidney disease education services
$0 copay $0 copay
FITNESS AND WELLNESS SilverSneakers ® Fitness Program - Basic fitness center membership including fitness classes.
HOSPICE You must get care from a Medicare-certified hospice. You must consult with your plan before you select hospice.
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2019 -13- Summary of Benefits
Notes
2019 -14- Summary of Benefits
Notes
Discrimination is Against the Law Humana Inc. and its subsidiaries comply with applicable Federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity, or religion. Humana Inc. and its subsidiaries do not exclude people or treat them differently because of race, color, national origin, age, disability, sex, sexual orientation, gender identity, or religion.
Humana Inc. and its subsidiaries provide: (1) free auxiliary aids and services, such as qualified sign language interpreters, video remote interpretation, and written information in other formats to people with disabilities when such auxiliary aids and services are necessary to ensure an equal opportunity to participate; and, (2) free language services to people whose primary language is not English when those services are necessary to provide meaningful access, such as translated documents or oral interpretation.
If you need these services, call 1-866-396-8810 or if you use a TTY , call 711 . If you believe that Humana Inc. and its subsidiaries have failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity, or religion, you can file a grievance with Discrimination Grievances, P.O. Box 14618, Lexington, KY 40512-4618.
If you need help filing a grievance, call 1-866-396-8810 or if you use a TTY , call 711 . You can also file a civil rights complaint with the U.S. Department of Health and Human Services , Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf , or by mail or phone at U.S. Department of Health and Human Services , 200 Independence Avenue, SW, Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, 800-537-7697 (TDD) . Complaint forms are available at https://www.hhs.gov/ocr/office/file/index.html .
1-866-396-8810 1-866-396-8810
1-866-396-8810 1-866-396-8810
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1-866-396-8810 1-866-396-8810
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1-866-396-8810 1-866-396-8810
1-866-396-8810
1-866-396-8810 1-866-396-8810
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GCHJV5REN_P 071118
(Pending CMS Approval) PPO 079/429
Humana is a Medicare Advantage organization with a Medicare contract. This is an advertisement. This information is not a complete description of benefits. Call 1-800-733-9064 (TTY: 711) for more information.
If you want to compare our plan with other Medicare health plans, you can call your employer or union sponsoring this plan to find out if you have other options through them. If you want to know more about the coverage and costs of Original Medicare, look in your current "Medicare & You" handbook. View it online at http://www.medicare.gov or get a copy by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.
Humana.com
You can see our plan's provider directory at our website at Humana.com or call us at the number listed at the beginning of this booklet and we will send you one.
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